My Story:
Updated!!!
Updated!!!
I’ve been fighting my weight since I was 14 years old. There has never been a time when I thought of myself or saw myself as healthy; and most of the time felt ashamed that I was so large. Throughout my high school years, I tried weight training, exercise, fad diets, and counseling to no avail.
When I went to college, I tried Jenny Craig, Weight Watchers, Overeaters Anonymous, and hypnotherapy, also with no change. And instead of maintaining my weight, I was gaining more.
I started having serious physical and psychological issues because of my weight. I tried taking my own life five different times when I was a teenager because I was so despondent about my weight.
Finally, just as things began to look their worst, Fen-Phen came out. I started taking it, and lost a total of 60 pounds. It was wonderful—while it lasted. I had taken it for three months, and it was pulled off the shelves. I did not change the physical activity level, and did not increase in the amount of food intake, and yet gained all 60 pounds right back, and then some.
I was devastated. I could not believe in myself anymore, and became increasingly touchy about the subject. When I joined with PacifiCare Insurance Network, I immediately went to my PCP, Dr. Susan Blake, for a physical, and was told I may be manic-depressive. She suggested I start taking Prozac to see what would happen with my mood swings. Happily enough, it started to work, but I was still very emotionally upset about my physical condition.
Above all else, I was physically in pain due to the excess weight. My feet, ankles, knees, hips and lower back were all suffering severely. Also, I began to have symptoms indicative of gall bladder disease and gastric reflux. These were excruciating on top of the joint and muscle aches. It got to the point where it was difficult to go to work each day because of them.
In August, I heard of a doctor outside of PacifiCare’s network in the Portland area who did a specific surgery that could change my life. I got in contact with Dr. McConnall, and found that there were 2 different surgeries that he did:
The first one, gastric bypass surgery, was relatively common, and involved stapling the stomach into a small pouch and re-routing a part of the intestines to the top of the pouch. Most bariatric and cosmetic surgeons know and perform this surgery.
The second one, a far more invasive procedure, is called a biliopancreatic bypass surgery. This is the re-creation of the stomach by suture and staples to a tube of about 155cc's, and a re-direction of the intestines, including a shortening of the lower bowel measuring anywhere from 125cm to 300cm from the top of the colon up. The doctor I went to was the only one in the state of Oregon who did this surgery.
In September, I contacted PacifiCare and informed them I wanted to see this specialist for a consultation. They refused to cover it, stating that they did not see any reason to do so. I paid for the visit out of pocket. I then wrote to them advising them I sought their approval to perform the 2nd surgery under insurance coverage because it was found that I my BMI (Body Mass Index) was 20 points higher than the minimum to be diagnosed as morbidly obese. I also sited my physical and emotional problems stemming from being so overweight. I included both surgery information and all other information pertaining to bariatric surgery as a whole. They refused, ignoring the second surgery option altogether, and stating that gastric stapling was not covered under their insurance (as if I didn't know this). By this time, it was January of 1999.
I wrote them again, siting the second surgery yet again, and adding in the information that my in-network doctor felt that this surgery was necessary for me to maintain my physical and mental health. They finally offered me a tribunal hearing on February 11th, to voice my reasons and give them a clear picture of why they should cover the surgery.
The tribunal was held, and I had my say. Two days later, I received a letter enclosed with the new 1999 handbook (previously unviewed by me, as my work had not yet received them). The letter once again denied coverage of the surgery because the new 1999 handbook excluded obesity surgery specifically, and they therefore could not make an exception.
I appealed to them again, and this time my appeal went to the Board of Directors. They spent almost three months in replying to my appeal, at which time, I went ahead and scheduled the surgery, thinking (apparently erroneously) that they couldn’t deny me yet again.
The letter I received back stated that I had been correct, they could not deny me based on 1999 coverage if the claim and appeal was started in 1998, however, they wanted to make sure that I met the medical requirements. They sent my PCP TAG guidelines that I was to meet, and if I did meet them, my PCP could request the surgery of UHN.
Dr. Blake read through them and interpreted that the only criteria I needed to meet was to make sure my BMI was over 40. As it was 20 points higher, I more than qualified. My PCP immediately wrote a letter stating that I fit the criteria, as she was finally becoming just as worried about my continued failing health as I was.
I received a denial from UHN regarding a Dr.’s office visit with a Dr. Friedman, which had nothing to do with the surgery, and I believe to be due to a referral my PCP had sent in a year ago that had been approved. I finally received the actual reason for denial from my PCP instead of UHN. The TAG guidelines had not been met because we had not interpreted them correctly. Not only did my BMI have to be over 40, but I also had be clinically diabetic, not have a severe psychological disorder, have an obesity problem for 5+ years, be able to take care of myself, and be pre-approved for the surgery.
By this time, it was August 16th. I went in for a chem-scan, and as I had a blood sugar level of 133, I was diagnosed with diabetes. Thankfully, it was high enough only to be diet controlled. I changed my diet, and found that I no longer needed the Prozac, since the mood swings were due to the massive sugar highs and lows.
My PCP and I both called up and wrote letters, and we were referred to Kent Gould at UHN. He didn’t get back to me until the 27th of August. He said that he would be speaking with the Medical Director and they would see if I truly fit the guidelines. He requested that I call back on Monday.
I did so, and found that the Medical Director had left for a conference and wouldn’t be back until Thursday. There was no way to get in touch with him, and I would just have to wait. I tried calling his office several times, and was finally referred back to PacifiCare to speak with Dr. Markie Roland.
Dr. Roland finally called me after 2 days (late in the day Sept 1st, the scheduled date of my surgery). I was advised through a voice mail that I would simply have to start the appeal process over again with PacifiCare, and there was nothing more for her or anyone else to do for me.
At the same time, due to the lack of communication, and the continued refusal of both PacifiCare and UHN, my surgeon (Dr. McConnall) was forced to cancel the surgery, as I did not have $24,000 to give to him right away. I was unable to get in touch with my mother before she left her home over 600 miles away. She was driving down to take care of me, and was forced to spend a fruitless drive down, and then back up to her home.
I finally got in touch with the Medical Director of UHN, Dr. Bonazola, Friday, Sept 3rd. He advised me that even though he was the Medical Director, he had no power over UHN's decision, and since it had been overturned, I would have to go back to PacifiCare and see what they said.
